Draft Irish Abortion Law: Protection of Conscience

Testimony before the Joint Committee on Health and Children

Houses of the Oireachtas (Tithe an Oireachtais)

20 May, 2013

Redacted Agenda:

• Psychiatry and Perinatal Psychiatrists
• Psychiatry

Psychiatry and Perinatal Psychiatrists

Redacted Witness List:

• Dr. Anthony McCarthy: 
  President, College of Psychiatrists of Ireland

• Dr. Joanne Fenton: 
  Consultant adult psychiatrist, specialist perinatal psychiatrist, Coombe Women and Infants University Hospital [Written Submission]

• Dr. John Sheehan: 
  Perinatal psychiatrist, Rotunda Hospital, Dublin [Written Submission]

Dr. Anthony McCarthy:  There are concerns among many psychiatrists that somehow this legislation will result in them being placed in very difficult clinical circumstances. For some this is because of their religious, philosophical or ethical beliefs, and these must be respected. I welcome that those views will be heard today as well. For others, there is a fear of increased workload for their already overstretched services, and doing this with no extra resources. For others it is a fear of being faced with very difficult clinical issues and dilemmas where, for example, a woman may be genuinely highly distressed, such as after rape, and wants a termination but is assessed as not being actively suicidal because she does not want to die. This woman may just want an end to the pregnancy but she will have to be refused an abortion under this legislation. That will be difficult for her and us as clinicians.
[P. 2, accessed 2013-05-27]

Dr. Joanne Fenton:  Many psychiatrists do not wish to partake in the assessments of these women for many reasons and their concerns must be respected. In my role as a perinatal psychiatrist I believe it is my responsibility to continue to assess pregnant women in distress and aim to provide the best and most compassionate care to them.
[P. 3, accessed 2013-05-27]

Dr. John Sheehan: I thank the committee for the opportunity to contribute. I am a perinatal psychiatrist working in the Rotunda Hospital in Dublin. A perinatal psychiatrist is a psychiatrist based in a maternity hospital and he or she treats women in pregnancy or, for example, following delivery. I also work as a liaison psychiatrist in the Mater Hospital, Dublin, which has one of the busiest accident and emergency departments in Ireland. Last year, we had the highest number of treated episodes of attempted suicide in the State, and part of my work is assessing and treating people who present with attempted suicide. I therefore work both in a perinatal setting and in an accident and emergency department setting.

I will confine my comments to the aspect of the Bill that is pertinent to psychiatry, namely head 4, which is concerned with the risk of loss of life from self-destruction. It has major implications for psychiatrists. First, there is a fundamental difference in the management of medical and psychiatric emergencies in obstetrics. In obstetrics, medical emergencies and psychiatric emergencies require different interventions. In a medical emergency, speedy delivery of the baby is required while, in a psychiatric emergency, speedy delivery of the baby is contraindicated. It is exactly the opposite of that required in a medical emergency. In a psychiatric emergency such as when a patent is depressed and has suicidal intent, the patient may have impaired capacity and should be advised not to make irrevocable decisions. The patient probably cannot give informed consent. Those of us who see people with suicidal intent often see people who feel overwhelmed, unsupported and hopeless and who are often desperate and agitated. The person often has what is called cognitive constriction and can see no other option in front of them except ending his or her life. Such a patient needs professional help, not an urgent termination of pregnancy.
[P. 4, accessed 2013-05-27]

Deputy Caoimhghín Ó Caoláin:   . . .For the panel, there is a requirement for three professional opinions, somebody from obstetrics and two psychiatrists. I would like to ask for your individual opinion. We would like to know, whether, in the witnesses' respective opinions, this number is too high? Does the requirement of unanimity of all three medical professionals render it difficult or, perhaps, even unworkable in practice and place an undue burden on the woman? In relation to their respective experiences - and they have indicated they reflect both City of Dublin and outside the City of Dublin experiences - will the issue of conscientious objection have any impact on the numbers available, those in practice associated with the respective 19 indicated-for-approval sites? Many psychiatrists are not actually associated with any of these yet one must be in terms of the way the draft legislation is presented. Do you see difficulties presenting there? In your own opinion, who should lead the process? It is not clear in the legislation whether it should be an obstetrician or two psychiatrists. One would expect it would be one, at least, of the two psychiatrists and that person would be attached to the individual site.
[P. 5, accessed 2013-05-27]

Dr. Anthony McCarthy:  We pointed out in our submissions real practical difficulties because of conscientious objectors - I fully support conscientious objectors - about the heads of the Bill as there could be one, for example, Dr. Sheehan, working in the Rotunda on his own. If he does not agree or I do not agree in my hospital, there must be a panel of persons outside and that must be looked at in the heads of the Bill.
[P. 6, accessed 2013-05-27]

Dr. John Sheehan:  The Senator made a point about good medicine. I have not looked at the issue of conscientious objection - I have been focusing on head 4, which deals with a woman who has suicidal intent and whose life can only be saved by a termination of pregnancy.
[P. 15, accessed 2013-05-27]

Dr. John Sheehan: As stated, Dr. McCarthy, Dr. Fenton and I, with more than 40 years combined experience, have not seen one case in our work as perinatal psychiatrists. The question about what the Bill, if enacted, might do to the position of psychiatrists was raised. That was one of the points I tried to address earlier. I believe it will cast psychiatrists into a role they have not been in to date. That is a change in role for psychiatrists. It is quite different to, for example, the working of the Mental Health Act, under which there is the option of detention of a person with increasing suicidal risk. This Bill as drafted deals with the woman with increasing suicidal intent whose life can only be saved by a termination of pregnancy, which is an entirely different situation.
[P. 16, accessed 2013-05-27]

Deputy Billy Timmins:   It is clear to me based on what I heard in January and today and from various submissions I have received, that there is clear division within the profession of psychiatrists. Unfortunately, it is that profession with whom the buck will ultimately stop. I do not envy them their position. Dr. McCarthy stated that many in the profession predominantly believe that this is a social and political issue. Unfortunately, it has landed at the door of professional psychiatrists.
[P. 16, accessed 2013-05-27]

Psychiatry

Redacted Witness List:

• Dr. Yolanda Ferguson: 
  Consultant general adult & community psychiatrist (Dublin south central psychiatric service & Tallaght Hospital) [Written Submission]

• Dr. Peadar O'Grady: 
  Doctors for Choice Ireland [Written Submission]

• Professor Veronica O'Keane: 
  Professor of psychiatry, Trinity College Dublin [Written Submission]

• Dr. Seán Ó Domhnaill: 
  Consultant psychiatrist [Written Submission]

• Dr. Jacqueline Montwill: 
  Consultant psychiatrist, Mayo Mental Health Service [Written Submission]

Deputy Bernard J. Durkan:   I thank the expert witnesses for their attendance today and their clear responses. I wish to comment on the Women Hurt group. It was suggested on Friday that in many cases women who had abortions outside of this jurisdiction and had feelings of guilt afterwards had a prior psychiatric condition. Is that generally accepted? To what extent has the evidence of the Women Hurt group, who came before another group in the House, been adduced, if at all?

Given the tendency in this country to have an Irish solution to an Irish problem, is there evidence to suggest that in certain circumstances, by virtue of the existence of conscientious objection, there is a possibility that some women presenting with a crisis pregnancy might find themselves unable to access treatment appropriate to their condition, either from a psychiatric point of view or medical point of view?
[P. 30, accessed 2013-05-27]

Dr. Yolanda Ferguson:  It is important that conscientious objection be included in the Bill. That is why we suggest a panel. If a woman cannot avail of the normal pathway of care because her psychiatrist is a conscientious objector, that panel should be formed.
[P. 31, accessed 2013-05-27]

Dr. Peadar O'Grady: . . . As to whether conscientious objection would disrupt access, that could be the case, and the issue will have to be monitored. It has been noted in ethical papers that there is a conscientious objection to the restriction of abortion. Doctors such as me would face criminal sanction if we were to exercise our right to assist a woman in following up and having an abortion on the basis of her decision of informed consent. This in contrast to those who wish to have a conscientious objection not to take part in the process. While I believe people should have every right not to take part, this right should not be an institutional one.
[P. 32, accessed 2013-05-27]

Professor Veronica O'Keane:  . . . On conscientious objectors, it is important to ask whether it will delay a woman's access to an abortion if her local psychiatrist is a conscientious objector. This is an incredibly important point and it is the reason I and others have proposed the establishment of a national panel. We could screen the panel for people who are prepared to co-operate in the full spirit of the law. If the local psychiatrist is on the panel, that is fine, and he or she can be requested to determine eligibility. However, if he or she is not on the panel, the woman would be poorly served by seeing somebody who did not want to comply with the legislation. For this reason, it is important to have a panel where it is stated that specific psychiatrists are happy to work within the legislative framework.
[P. 32, accessed 2013-05-27]

Dr. Seán Ó Domhnaill: I had better respond to the question about why I might have concerns about head 4 in relation to the assessment of colleagues who might deem people as being suicidal and who might be prepared to sign off on forms that would allow them to travel for abortions or to have abortions because of mental health issues. Quite honestly, the reason is that I have worked in other jurisdictions and in the very first jurisdiction in which I worked where abortion was legal, which was Jersey in 1997, I saw consultant colleagues at that time who signed off in advance. I remember one particular individual who had a pile of forms pre-signed, and the reason for that simply was that the ideology of that individual was completely pro-choice and they had so little regard for the unborn child or for the rights of the unborn child. My concern is that we would reduce the value of the life of the unborn, as this Bill seeks to do for the first time ever. This is the first time a piece of legislation seeks to allow any human being in this country to be killed. That is how serious this is. We outlawed the death penalty. The only person at risk in this country at the moment of having a death warrant signed is an unborn child.
[P. 40, accessed 2013-05-27]

Dr. Seán Ó Domhnaill: On the question of why have the fear that somebody is going to sign these forms if suicidality is not a ground for abortion, again, ideology is an incredibly strong thing and there are those who cannot see beyond their ideology. I believe and hope that as clinicians - many of us consider ourselves somewhat vocational in our work - we are able to go beyond our own ideologies to provide the best possible treatment. However, the people who are watching and who will read the record of this hearing now and down the years may wonder what we were so afraid of.
[P. 42, accessed 2013-05-27]

Dr. Jacqueline Montwill: I can answer that. Colleagues have already stated that they want to have a panel of doctors who will not obstruct the process. I presume, therefore, that there will be some kind of bias. The second issue is that, as we have stated from the beginning, there is no way we can say which patient will kill herself. To be honest, I am not sure how many women with a crisis pregnancy have committed suicide. However, we can never say that it could not happen. Under the proposed legislation, if a woman tells the panel she will kill herself, what psychiatrist can say she will not kill herself?
[P. 50, accessed 2013-05-27]

Dr. Seán Ó Domhnaill: To respond to Senator Crown, he knows my position on abortion. It has been made clear by some of the psychiatrists who have appeared today that anyone who holds my position on abortion should be excluded from the panels. If all doctors who believe that abortion is not a treatment for suicidality are excluded, we will be left with certain psychiatrists and their friends. We are relying on the Oireachtas to provide a safeguard. That is the simple truth of the matter.
[P. 50, accessed 2013-05-27]

Senator John Crown:   On a point of information, the evidence base in medicine is available for all doctors who can all see the same evidence. There is not different evidence for different doctors.
[P. 50, accessed 2013-05-27]